Antihypertensives - ACE inhibitors

Question 1

Renin in the blood converts angiotensinogen into angiotensin I. Angiotensin converting enzyme (ACE) converts angiotensin I into angiotensin II. Which of the following is NOT a function of angiotensin II?

1 - blood vessels vasoconstriction
2 - vasoconstricts afferent and efferent arterioles of glomerulus (preference on efferent arterioles though)
3 - vasodilates efferent arterioles of glomerulus
4 - binds proximal tubules, increase Na+ and H20 retention
5 - binds adrenal cortex, releasing aldosterone

Answer 1

3 - vasodilates afferent and efferent arterioles of glomerulus

• aldosterone increases Na+ and H2O retention

Question 2

Renin is released from the juxtaglomerular cells of the kidneys. What is the function of renin?

1 - convert angiotensin I into angiotensin II
2 - converts angiotensinogen into angiotensin I
3 - increases anti-diuretic hormone release
4 - increases the release of aldosterone from adrenal glands

Answer 2

2 - converts angiotensinogen into angiotensin I

Question 3

Which of the following is NOT a core ACE inhibitor drug that we need to know?

1 - Ramipril
2 - Lisinopril
3 - Enalapril
4 - Candesartan

Answer 3

4 - Candesartan

Question 4

The core ACE-I inhibitors we need to be aware of are Ramipril, Lisinopril and Enalapril. Of these which is most commonly used?

Answer 4

• Ramipril

Question 5

Ramipril, Lisinopril and Enalapril are the core ACE inhibitor drugs. What is the mechanism of action of this drug?

1 - binds and inhibits ACE receptors
2 - inhibits ACE
3 - inhibit beta receptors
4 - inhibit alpha receptors

Answer 5

2 - inhibits ACE

• RLE or REL

Question 6

If a patient is <55 y/o and caucasian, the following guidelines are used for treating hypertension.

• Stage 3: SBP >180 mmHg Treat immediately
• Stage 2: BP >160/100 mmHg Treat once confirmed on 24hr BP
• Stage 1: BP > 140/90 mmHg Treat if end-organ damage or if diabetic

Which of the following is indicated as a first line medication for hypertension?

1 - α-blockers
2 - β-blockers
3 - ACE inhibitors
4 - Calcium channel blockers

Answer 6

3 - ACE inhibitors

• also 2nd line in >55 y/o and black patients, who are less responsive to ACE inhibitors
• could also prescribe a Angiotensin-II receptor blockers

Question 7

ACE inhibitors are indicated in which 2 of the following conditions?

1 - embolism
2 - chronic heart failure
3 - 2nd prevention of major cardiovascular event
4 - DVT

Answer 7

2 - chronic heart failure
- 1st line for all grades of heart failure

3 - 2nd prevention of major cardiovascular event
- patients with ischaemic heart disease, cerebrovascular disease and PVD

Question 8

ACE inhibitors block the ACE from functioning and therefore block the release of a specific hormone being released from the adrenal glands. What is this hormone called?

1 - aldosterone
2 - cortisol
3 - drenaline
4 - noradrenaline

Answer 8

1 - aldosterone

• by excreting Na+ and H2O reduces venous return and preload and reduces workload on the heart

Question 9

Which drug is indicated in patients with CKD with proteinuria?

1 - α-blockers
2 - β-blockers
3 - ACE inhibitors
4 - Calcium channel blockers

Answer 9

3 - ACE inhibitors

• dilates efferent arteriole and thus lowers pressure and eGFR
• reduces SVR and lowers BP
• all end in pril

Question 10

ACE inhibitors are indicated in patients with CKD with proteinuria. Do ACE cause vasodilation of the efferent or afferent glomerular arteriole?

Answer 10

• efferent arteriole
• vasodilating the efferent arterioles reduces pressure in the glomerulus and reduces kidney damage

Question 11

Which if the following in diabetes patients indicates the use of ACE inhibitors?

1 - diabetic ketoacidosis
2 - diabetic peripheral neuropathy
3 - diabetic nephropathy
4 - diabetic retinopathy

Answer 11

3 - diabetic nephropathy

Question 12

ACE inhibitors are indicated in patients with CKD with proteinurea.

Question 13

A common adverse effect of ACE inhibitors is which of the following?

1 - hypernatraemia
2 - hypokalaemia
3 - hypercalcaemia
4 - hyperkalaemia

Answer 13

4 - hyperkalaemia

• kidneys excrete Cl- and Na+ and retain K+

Question 14

Can ACE inhibitors cause hypo or hypertension following the 1st dose as an adverse event?

Answer 14

• hypotension

Question 15

Although ACE inhibitors are able to reduce SVR and vasodilate the efferent arteriole of the glomerulus, is this always good?

Answer 15

• no
• vasoconstriction of efferent arteriole is important for maintaining glomerulus filtration, without this renal function can decline

Question 16

A common adverse event of ACE inhibitors is a dry cough. What is the cause of this?

1 - increased bradykinin
2 - increased sensitivity of cough receptors
3 - increased sensitivity of respiratory drive
4 - increased mucous production

Answer 16

1 - increased bradykinin

• ACE generally inactivates bradykinin

Question 17

ACE inhibitors should not be used in patients with renal artery stenosis and acute kidney injury for fear of making them worse. However, can ACE inhibitors ever be used in CKD?

Answer 17

• yes when CKD patients have proteinuria
• lower doses and close monitor should be conducted

Question 18

Why are ACE inhibitors not generally used in patients who are pregnant or breast feeding?

1 - foetal toxicity
2 - increases eGFR
3 - increases foetal immune suppression
4 - induces early labour

Answer 18

1 - foetal toxicity

• has been linked with foetal malformations

Question 19

Why should ACE inhibitors not be prescribed alongside K+ elevating drugs such as aldosterone antagonist and potassium sparing diuretics?

1 - ACE inhibitors increase K+ release
2 - ACE inhibitors inhibit aldosterone release
3 - ACE inhibitors increase aldosterone release
4 - ACE inhibitors damage adrenal glands

Answer 19

2 - ACE inhibitors inhibit aldosterone release

• combined with other drugs this would amplify hyperkalaemia
• may only be used together in some heart failure patients, BUT closely supervised

Question 20

Which drug class combined with ACE inhibitors can increase the risk of nephrotoxicity?

1 - antidepressants
2 - statins
3 - paracetamol
4 - NSAIDs

Answer 20

4 - NSAIDs

Question 21

What is the common prescribed dose to start on for ramipril in heart failure or nephropathy?

1 - 1.25mg orally/day
2 - 2.5mg orally/day
3 - 5mg orally/day
4 - 10mg orally/day

Answer 21

1 - 1.25mg orally/day

• 2.5mg for all other indications
• can be titrated up to 10mg/day orally under close supervision over weeks

Question 22

If a patient is sick and develops diarrhoea and/or vomiting, should they continue to take their ACE inhibitors?

Answer 22

• no
• can further increase risk of dehydration and renal damage

Question 23

Prior to starting ACE inhibitors, which 2 of the following MUST be checked?

1 - FBC
2 - WBC
3 - eGFR
4 - U&Es

Answer 23

3 - eGFR
4 - U&Es

• both can be affected by ACE inhibitors
• should be repeated within 1-2 weeks and if dose changes

Question 24

ACE inhibitors can cause angioedema as a rare adverse event. What is this?

1 - swelling of the blood vessels
2 - swelling of the ureters
3 - swelling underneath the skin
4 - swelling in the kidneys

Answer 24

3 - swelling underneath the skin

Question 25

ACE inhibitors can generally be a lifetime drug, however, is this always the case?

Answer 25

• no
• if BP drops or a patient develops frailty or multi morbidity then ARB-II could be reduced or stopped altogether

Question 26

In patients <80 y/o with hypertension, what are the NICE guidelines for BP?

1 - 130/85
2 - 140/90
3 - 150/90
4 - 160/90

Answer 26

2 - 140/90
- 130/85 in diabetes
- 150/90 in >80 y/o